Treatment for OCD & Depression (PDF)

11/16/23, 11:27 AM Realizeit for Student Treatment Optimal treatment for OCD combines medication and behavioral therapy. SSRI antidepressants, such as fluvoxamine (Luvox) and sertraline (Zoloft), are first-line choices, followed by venlafaxine (Effexor). Treatment-resistant OCD may respond to seco...

11/16/23, 11:27 AM Realizeit for Student Treatment Optimal treatment for OCD combines medication and behavioral therapy. SSRI antidepressants, such as fluvoxamine (Luvox) and sertraline (Zoloft), are first-line choices, followed by venlafaxine (Effexor). Treatment-resistant OCD may respond to second-generation antipsychotics such as risperidone (Risperdal), quetiapine (Seroquel), or olanzapine (Zyprexa). Children and adolescents with OCD also respond well to behavioral therapy and SSRI antidepressants, even when symptoms are treatment refractory (Casale et al., 2018). Antianxiety Drugs (Anxiolytics) Antianxiety drugs, or anxiolytic drugs, are also used to treat obsessive-compulsive disorder (OCD). Side Effects Although not a side effect in the true sense, one chief problem encountered with the use of benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine use, such as those with panic disorder or generalized anxiety disorder. Psychological dependence on benzodiazepines is common; clients fear the return of anxiety symptoms or believe they are incapable of handling anxiety without the drugs. This can lead to overuse or abuse of these drugs. Buspirone does not cause this type of physical dependence. The side effects most commonly reported with benzodiazepines are those associated with CNS depression, such as drowsiness, sedation, poor coordination, and impaired memory or clouded sensorium. When used for sleep, clients may complain of next-day sedation or a hangover effect. Clients often develop a tolerance to these symptoms, and they generally decrease in intensity. Common side effects from buspirone include dizziness, sedation, nausea, and headache (Stahl, 2017). Elderly clients may have more difficulty managing the effects of CNS depression. They may be more prone to falls from the effects on coordination and sedation. They may also have more pronounced memory deficits and may have problems with urinary incontinence, particularly at night. Client Teaching Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol; one drink while on a benzodiazepine may have the effect of three drinks. Therefore, clients should not drink alcohol while taking benzodiazepines. Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work. Benzodiazepine withdrawal can be fatal. After the client has started a course of therapy, he or she should never discontinue benzodiazepines abruptly or without the supervision of the physician (Burchum & Rosenthal, 2018). Other Drugs in the Class . The FDA has approved clomipramine for treatment of obsessive–compulsive disorder in children. In general, amitriptyline, clomipramine, desipramine, doxepin, and nortriptyline are similar to imipramine in terms of adverse effects. Amitriptyline and doxepin are more likely to cause weight gain. Desipramine is more likely to cause drowsiness. These TCAs are effective; however, antidepressants that produce fewer adverse effects are increasingly replacing them. Selective Serotonin Reuptake Inhibitors SSRIs, of which fluoxetine (PROzac, Sarafem) is the prototype, produce fewer serious adverse effects than the TCAs. (SSRIs are called “selective” because they seem to primarily affect serotonin and not other neurotransmitters.) The drugs of first choice in the treatment of depression, SSRIs are effective and usually produce fewer and milder adverse effects than other antidepressants. There are no guidelines for choosing one SSRI over another. Pharmacokinetics Fluoxetine is well absorbed with oral administration, with a peak of action of 6 to 8 hours. The half-life of elimination for the parent drug is 2 to 3 days; this may lead to accumulation with chronic administration. (An active metabolite has a half-life of 7 to 9 days.) Thus, steady-state blood levels are achieved slowly, over several weeks, and drug effects decrease slowly (over 2 to 3 months) when fluoxetine is discontinued. The drug is present in breast milk. Metabolism takes place in the liver, and excretion predominately occurs in the kidneys. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 1/6 11/16/23, 11:27 AM Realizeit for Student Action Fluoxetine blocks the reabsorption of the neurotransmitter serotonin in the brain. This helps elevate the patient's mood. Fluoxetine has no effect on the norepinephrine or dopamine. Use Uses for fluoxetine include the treatment of depression and its associated anxiety, obsessive–compulsive disorder, bulimia nervosa, and premenstrual dysphoric disorder. Use in Children The FDA has issued a BLACK BOX WARNING ♦ alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications, including fluoxetine. Use in Older Adults Fluoxetine and other SSRIs are the drugs of choice in older adults because they produce fewer sedative, anticholinergic, cardiotoxic, and psychomotor adverse effects than the TCAs and related antidepressants. Elimination may be slower, and smaller or less frequent doses may be prudent in older adults. Weight loss is often associated with SSRIs and may be undesirable in older adults. Use of maintenance antidepressant therapy is beneficial to prevent recurrence of depression in older adults. Use in Patients With Hepatic Impairment Hepatic impairment leads to reduced first-pass metabolism of fluoxetine and most antidepressant drugs, resulting in higher plasma levels. Thus, caution is warranted in severe liver impairment. Use in Patients With Critical Illness Patients who are critically ill may need a drug to combat the depression that often develops with major illness. The decision to start fluoxetine should involve a thorough assessment of the patient's Patients who are critically ill may need a drug to combat the depression that often develops with major illness. The decision to start fluoxetine should involve a thorough assessment of the patient’s condition, other drugs being given, and potential adverse drug effects. Antidepressants, including imipramine, warrant caution perioperatively because of the risk of serious adverse effects and adverse interactions with anesthetics and other commonly used drugs. Adverse Effects Adverse effects of fluoxetine include a high incidence of GI symptoms (e.g., nausea, diarrhea, and weight loss) and sexual dysfunction (e.g., delayed ejaculation in men, impaired orgasmic ability in women). Most SSRIs also cause some degree of CNS stimulation (e.g., anxiety, nervousness, insomnia), which is most prominent with fluoxetine. These drugs are also associated with increased risk of GI bleeding. For patients with diabetes mellitus, SSRIs may have a hypoglycemic effect. Serotonin syndrome, a serious and sometimes fatal reaction characterized by hypertensive crisis, hyperpyrexia, extreme agitation progressing to delirium and coma, muscle rigidity, and seizures, may occur due to combined therapy with an SSRI and an MAO inhibitor or another drug that potentiates serotonin neurotransmission. It is important not to take an SSRI or SNRI and an MAO inhibitor concurrently or within 2 weeks of each other. In most cases, if a patient taking an SSRI is transferred to an MAO inhibitor, it is necessary to discontinue the SSRI at least 14 days before starting the MAO inhibitor. However, the patient should discontinue fluoxetine at least 5 weeks before starting an MAO inhibitor due to the prolonged half-life. As previously discussed, antidepressant discontinuation syndrome can occur with sudden termination of the SSRIs. Withdrawal symptoms include dizziness, GI upset, lethargy or anxiety/hyperarousal, dysphoria, sleep problems, and headache, which can last from several days to several weeks. More serious symptoms may include aggression, hypomania, mood disturbances, and suicidal tendencies. Fluoxetine, with its long half-life, has not been associated with withdrawal symptoms. Contraindications Contraindications to fluoxetine include known sensitivity to the drug as well as the use of MAO inhibitors or thioridazine. QSEN Alert: Safety https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 2/6 11/16/23, 11:27 AM Realizeit for Student People of any age who have attempted suicide should not receive fluoxetine. Nursing Implications Preventing Interactions Because fluoxetine and other SSRIs are highly bound to plasma proteins, they compete with endogenous compounds and other medications for binding sites, resulting in drug interactions. Several drugs increase the effects of fluoxetine. Also, CYP2D6 enzymes metabolize fluoxetine; therefore, the drug may cause accumulation of other drugs using this enzyme system (e.g., amitriptyline, imipramine, desipramine, thioridazine). QSEN Alert: Safety In addition, fluoxetine can prevent the conversion of codeine to its active form, resulting in lack of pain relief when the drugs are used concurrently. Administering the Medication People typically take SSRIs, including fluoxetine, once daily in the morning to prevent interference with sleep. They may take the drug with food to avoid GI upset. The nurse advises the patient to use sugar-free gum or hard candies to counteract dry mouth. Assessing for Therapeutic Effects The nurse assesses for statements of improved depression. He or she assesses improvement in appetite, physical activity, and interest in surroundings; improved sleep patterns; improved appearance; decreased anxiety; and reduced somatic complaints. The patient response to fluoxetine can significantly vary from patient to patient. The full response of the medication may not be seen for 8 to 12 weeks. Therapeutic serum levels of fluoxetine range from 100 to 800 ng/mL. Assessing for Adverse Effects The nurse assesses for dizziness, headache, nervousness, insomnia, nausea, diarrhea, dry mouth, sedation, skin rash, and sexual dysfunction. QSEN Alert: Safety It is essential to assess for suicidal thoughts or plans, especially at the beginning of therapy or when dosages are increased or decreased. Patient Teaching Patient Teaching Guidelines for Antidepressants General Considerations Take antidepressants as directed to maximize therapeutic benefits and minimize adverse effects. Do not alter doses when symptoms subside. Antidepressants are usually given for several months, perhaps years. Therapeutic effects (relief of symptoms) may not occur for 2 to 4 weeks after drug therapy is started. As a result, it is very important not to think the drug is ineffective and stop taking it prematurely. Continue to take the drug even if you feel better to prevent the return of depression. Do not take other prescription or over-the-counter drugs, including cold remedies, without consulting a health care provider. Potentially serious drug interactions may occur. Do not take the herbal supplement St. John’s wort while taking a prescription antidepressant. Serious interactions may occur. Inform any physician, surgeon, dentist, or nurse practitioner about the antidepressants being taken. Potentially serious adverse effects or drug interactions may occur if certain other drugs are prescribed. Avoid activities that require alertness and physical coordination (e.g., driving a car, operating other machinery) until reasonably sure the medication does not make you drowsy or impair your ability to perform the activities safely. Avoid alcohol and other CNS depressants (e.g., any drugs that cause drowsiness). Excessive drowsiness, dizziness, difficulty breathing, and low blood pressure may occur, with potentially serious consequences. Learn the name and type of the prescribed antidepressant to help avoid undesirable interactions with other drugs or a physician prescribing other drugs with similar effects. There are several different types of antidepressants, with different characteristics and precautions for safe and effective usage. Do not stop taking any antidepressant without discussing it with a health care provider. If a problem occurs, the type of drug, the dose, or other aspects may be changed to solve the problem and allow continued use of the medication. Counseling, support groups, relaxation techniques, and other nonpharmacologic treatments are recommended along with drug therapy. Notify your physician if you become pregnant or intend to become pregnant during therapy with antidepressants. Self or Caregiver Administration https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 3/6 11/16/23, 11:27 AM Realizeit for Student With a tricyclic antidepressant (e.g., amitriptyline), take at bedtime to aid sleep and decrease adverse effects. Also, report urinary retention, fainting, irregular heartbeat, seizures, restlessness, and mental confusion. These are potentially serious adverse drug effects. With a selective serotonin reuptake inhibitor, take the drug in the morning because it may interfere with sleep if taken at bedtime. In addition, notify a health care provider if a skin rash or other allergic reaction occurs. Allergic reactions are uncommon but may require that the drug be discontinued. Recognize the importance of follow-up and seeking professional help for the signs of dizziness or insomnia or other symptoms that negatively affect your life. Realize that escitalopram (Lexapro) is a derivative of citalopram (Celexa). The two medications should not be taken concomitantly. With venlafaxine (Effexor), take as directed or ask for instructions. This drug is often taken twice daily. Notify a health care provider if a skin rash or other allergic reaction occurs. An allergic reaction may require that the drug be discontinued. With venlafaxine, use effective birth control methods while taking this drug. Pregnancy is a contraindication. With duloxetine and desvenlafaxine, swallow the medication whole; do not crush, chew, or sprinkle capsule contents on food. With phenelzine and other monoamine oxidase inhibitors, foods that contain tyramine or tyrosine may have to be avoided altogether to prevent the risk of hypertensive crisis. This includes aged cheeses, coffee, chocolate, wine, bananas, avocados, fava beans, and most fermented and pickled foods. Bupropion is a unique drug prescribed for depression (brand name, Wellbutrin) and for smoking cessation (brand name, Zyban). It is extremely important not to increase the dose or take the two brand names at the same time (as might happen with different physicians or filling prescriptions at different pharmacies). Overdoses may cause seizures as well as other adverse effects. When used for smoking cessation, Zyban is recommended for up to 12 weeks if progress is being made. If significant progress is not made by approximately 7 weeks, it is considered unlikely that longer drug use will be helpful. There are short-, intermediate-, and long-acting forms of bupropion that are taken three times, two times, or one time per day, respectively. Be sure to take your medication as prescribed by your physician. Make sure that you and the people you live with are familiar with the signs and symptoms of worsening depression and know how to seek help for signs of overdose. Other Drugs in the Class Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibryd, Viibryd Starter Pack). Sertraline and citalopram also have active metabolites, but paroxetine, like fluoxetine, is more likely to accumulate. Escitalopram, paroxetine, and sertraline reach steady-state concentrations in 1 to 2 weeks. People may take the drugs in the morning or evening (but at the same time each day). An evening dose may interfere with sleep. The SSRIs are strong inhibitors of the CYP enzyme system, which metabolizes many drugs. As a result, serum drug levels and risks of adverse effects are greatly increased. Most significantly, fluoxetine, paroxetine, and sertraline slow metabolism of bupropion, codeine, desipramine, dextromethorphan, flecainide, metoprolol, nortriptyline, phenothiazines, propranolol, risperidone, and timolol. Vilazodone can produce discontinuation syndrome; its abrupt discontinuation or interruption will produce symptoms including nausea, vomiting, diarrhea, headache, lightheadedness, sweating, chills, tremors, paresthesias, somnolence, and sleep disturbances. Discontinuation of antidepressant treatment should last for >3 weeks. QSEN Alert: Safety With citalopram and escitalopram, poor metabolizers of CYP2C19 or concurrent use of moderate-to-strong CYP2C19 inhibitors (e.g., cimetidine, c receive half the maximum dose (20 mg) daily. Paroxetine, which has a half-life of approximately 24 hours and does not produce active metabolites, may be associated with antidepressant discontinuation syndrome even when discontinued gradually, over 7 to 10 days. Symptoms may include a flulike syndrome with nausea, vomiting, fatigue, muscle aches, dizziness, headache, and insomnia. Serotonin–Norepinephrine Reuptake Inhibitors Like the SSRIs, the SNRIs, of which venlafaxine (Effexor XR) is the prototype, inhibit the neuronal uptake of serotonin. In addition, they also inhibit the uptake of norepinephrine, increasing the activity of these neurotransmitters in the brain. The SNRIs are similar to SSRIs in terms of therapeutic effects. Pharmacokinetics and Action Venlafaxine is well absorbed, extensively metabolized in the liver, and excreted in urine. It crosses the placenta and may enter breast milk. The drug increases the levels of serotonin and norepinephrine in the brain by preventing the reuptake of these neurotransmitters known to play an important part in mood. The drug also weakly inhibits dopamine reuptake. Use SNRIs are a standard first-line treatment for depression and anxiety disorders. Uses for venlafaxine include the treatment of depression, as well as generalized anxiety disorder, social phobia, and panic disorder. Use in Children https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 4/6 11/16/23, 11:27 AM Realizeit for Student The FDA has issued a BLACK BOX WARNING ♦ alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications, including venlafaxine. Children who take the drug are quite likely to experience weight loss. Use in Older Adults Venlafaxine and other SNRIs are suitable for use in older people, although the weight loss often associated with these drugs may be undesirable. Authorities recommend using smaller initial doses and dosing increments. In addition, there is an increased risk of the syndrome of inappropriate antidiuretic hormone or hyponatremia in older adults. It is necessary to monitor sodium levels frequently. Use in Patients With Renal Impairment Venlafaxine is excreted by the kidneys; thus, dosage adjustment is necessary in patients with renal impairment. Use in Patients With Hepatic Impairment Caution is warranted in patients with hepatic impairment. Prescribers should consider lower doses, longer intervals between doses, and slower dose increases than usual. Use in Patients With Critical Illness Patients who are critically ill may need a drug such as venlafaxine to combat the depression that often develops with major illness. It is necessary to make a thorough assessment of the patient's condition, other drugs being given, potential adverse drug effects, and other factors before starting the drug. Adverse Effects Adverse effects of venlafaxine, which may be greater than with the SSRIs, include the following: CNS effects: anxiety, dizziness, dreams, insomnia, nervousness, somnolence, and tremors GI effects: anorexia, weight loss, nausea, vomiting, constipation, and diarrhea Cardiovascular effects: hypertension, tachycardia, and vasodilation Genitourinary effects: abnormal ejaculation, impotence, and urinary frequency. (The negative effect of venlafaxine on sexual function is less than that reported with the SSRIs.) Dermatologic effects: sweating, rash, and pruritus Contraindications Contraindications to venlafaxine include known sensitivity to the drug, use of an MAO inhibitor, and pregnancy. Nursing Implications Preventing Interactions Venlafaxine and other SNRIs interact with MAO inhibitors, leading to increased serum levels and the risk of serotonin syndrome. It is necessary to discontinue the MAO inhibitor at least 14 days before starting venlafaxine. Administering the Medication People should take venlafaxine with food to decrease its GI effects (e.g., nausea and vomiting). They should take the extended-release formulation in the morning and evening, at approximately the same time. For patients who have difficulty swallowing extended-release capsules, they can be opened and sprinkled on applesauce. The nurse instructs patient to swallow the applesauce and medication without chewing and to follow this by drinking a glass of water. This will ensure all pellets are swallowed. Assessing for Therapeutic Effects The nurse assesses for improvement in mood, including improvement in anxiety level, reduced agitation or irritability episodes, decreased number of panic attacks, and ability to sleep through the night. Assessing for Adverse Effects The nurse observes for dizziness, headache, nervousness, insomnia, nausea, diarrhea, dizziness, dry mouth, sedation, and skin rash. Also, it is necessary to assess for altered sexual function and provide options and resources for the patient and the significant other. In addition, the nurse evaluates for the occurrence of weight loss. Finally, it is important to monitor for signs of suicidal ideation and hostility. Second-Generation “Atypical” Antipsychotics https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 5/6 11/16/23, 11:27 AM Realizeit for Student Olanzapine (Zyprexa) is also used to manage schizophrenia and manic or mixed episodes of bipolar disorder. The drug can cause leukopenia and neutropenia, which increases the risk of infection. Other adverse effects include drowsiness, extrapyramidal symptoms, akathisia, Parkinson-like syndrome, dizziness, headache, increased serum prolactin, increased appetite, xerostomia, increased serum aspartate aminotransferase (AST), decreased serum bilirubin, and increased serum alanine aminotransferase (ALT). The drug is highly metabolized by CYP1A2 and CYP2D6 of the cytochrome P-450 system. About 40% of the drug is removed via first-pass metabolism. Drug interactions are likely with drugs that induce CYP1A2 (e.g., nafcillin, omeprazole, modafinil) or inhibit this enzyme (e.g., ciprofloxacin, verapamil, cimetidine). In addition, vegetables such as chargrilled meat, cabbages, broccoli, and cauliflower are known to increase levels of CYP1A2. Conversely, St. John’s wort, echinacea, peppermint, German chamomile, and dandelion teas, as well as tobacco, are inhibitors of CPY1A2. Drugs that induce (e.g., haloperidol, dexamethasone, glutethimide) or inhibit (e.g., quinidine, paroxetine, fluoxetine) CYP2D6 are known to interact with olanzapine. Risperidone (Risperdal, Perseris) is prescribed for the treatment of schizophrenia and acute bipolar mania. The drug is also used to manage children with autism spectrum disorders to reduce irritability-associated symptoms, including self-injury, aggression, tantrums, and mood swings. In schizophrenia, relief of positive and negative symptoms and improved cognitive function may occur in as little as 1 week. Generally, adverse effects are mild and include weight gain, diabetes, and dyslipidemia. A dose-related increase in extrapyramidal symptoms may occur with increased oral doses and the long-term formulation (Risperdal Consta), a depot preparation. Quetiapine (Seroquel, Seroquel XR) is prescribed to treat schizophrenia, depressive disorder, and manic episodes with bipolar disorder. Extended-release Seroquel XR is for use only in adults and should not be given to patients younger than 18 years old. Adverse effects include tachycardia, increased systolic and/or increased systolic and diastolic blood pressure, drowsiness, headache, agitation, dizziness, weight gain, increased serum total cholesterol, low-density cholesterol, triglycerides, and decreased high-density cholesterol, as well as xerostomia, constipation, and increased appetite. As with many atypical antipsychotic agents, the potential for clinically relevant drug interactions exists because the drug is metabolized by CYP2D6 and CYP3A4. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 6/6